The recent report of the Institute of Medicine concludes that there is a critical need for research designed to improve care at the end of life. Project ENABLE, a Robert Wood Johnson funded demonstration project designed to improve end-of-life care in cancer patients, showed that a palliative care model that focused on early intervention (at the time of diagnosis of advanced cancer), patient education, preference- based treatment and coordinated care is: 1) feasible to implement in a comprehensive cancer center; 2) accepted by oncologists who are focused on aggressive/clinical trials- oriented care; and 3) accepted and valued by patients and family members. This application is designed to refine the ENABLE intervention and increase its efficiency by integrating approaches developed by the Dartmouth Northern New England Cooperative Research Group that have focused on practice system changes that improve quality and efficiency of care. The primary goal of this application is to test the efficacy of an intervention for improving palliative care for cancer patients that includes: 1) the Dartmouth Clinical Improvement System which emphasizes rapid assessment of problems and feedback to patients (including tailored educational materials) and practitioners; 2) telephone- base nurse educators who will provide ongoing symptom and problem assessment, coordination of care between the cancer center health care team and other services, and education regarding problem-solving, communication with the healthcare team, advanced care planning and symptom management; and 3) Drop-In Group Medical Appointments (DIGMAs) for symptom management. Patients with advanced lung, gastrointestinal, and breast cancer seen at the Norris Cotton Cancer Center will be identified at diagnosis and randomized to receive the ENABLE II intervention or standard care. The primary hypotheses are: 1) Patients randomized to the ENABLE II intervention will report better symptom management, higher quality of life, a better match between preferences and the care received, and lower health care utilization as compared to patients in the standard care group and 2) Family members of patients receiving the ENABLE II intervention will report better quality of care, symptom management, and match between preferences and care received as measured by the After Death Interview. [unreadable] [unreadable]